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E Please print or type. Form Approved , OMB No . 2050.0039 UNIFORM HAZARDOUS i 7Generator ID Number 2. Page 1 of 3. Emergency Respons/e Phone 4. Manifest Tracking Number F! i 5 -`r '- l,_.9 A t' N M*.y �. � p � V WASTE MANIFEST 1' I 1 .� r� � � 5. Generator's Name and Mailing Address t "`j a Generator's Site Address (if different than mailing address) # . .,� Generator's Phone 6. Transporter 1 Company Name U.S. EPA ID gmber, _ . x � .; 7. Transporter 2 Company Name U .S. EPA ID Number 8, Desrgnated Facility Name and Site Address U .S, EPA ID Number ! iZI . . ! . : Facility's Phone: ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12. Unit 13. Waste Codes HM and Packing Group (if any)) No. Type Quantity Wt./Vol, . 0 � ?-rtIt) EF ip I Ff?+Jf } h f-4 z 2 . W 3. 4 . 14. Special Handling Instructions and Additional Information 15, GENERATOR' SIOFFEROR'S CERTIFICATION : I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified , packaged, marked and labeledlplacarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (ill am a small quantity generator) is true. Generators/Offeroes Printed/Typed Name Signature Month Day Year t 16. International Shipments ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: z Transporter signature (for exports only): Date leaving U.S.: W 17, Transporter Acknowledgment of Receipt of Materials Transporter ,Printe fyped Name - j Signature � r Month Day Year ( / ( ` z Transporter 2 PrinlediTyped Name Signature ( 1 Month Day Year r- 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 181b. Alternate Facility (or Generator) U .S. EPA ID Number U ca+. Facility's Phone : W 18c. Signature of Alternate Facility (or Generator) P ionth Day Year Z Z h19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 0 1 . 2. 3. 4. 20, Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as nc ed in Item 18a PrintedlTyped Name Signature Month Day Year EPA Form 8700.22 (Rev. 12-17) Previous editions are obsolete . GENERATOR' S INITIAL COPY